GW1--06212_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. IWelll Contractor
�f Information:
9ILt h °►. r 1L7.2r1b/d 14.WATER ZONES I
Well ConctorName C11 FROM TO DESCRIPTION '
3��� .ooIL 3�'df4 drh--
ft ft.
NLC�Well Contractor Certification Number\ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licablle)
G7 P Nam .S W.E�I cL Jri 111 VILl I h G. FROMTO f` DIAMETERttin. -CK /® � MATERIALNESS �V
Com 7 q 16.INNER CASING"(eee OR TUBiN/GO'(geothermal closed-loop)
2.Well Construction Permit#: 11-"1-4-3(J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) R. rt. in-
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN N bet
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft f. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
tt it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO GMAT 1L ACEMENT M¢THOD&AMOUNT
Non-Water Supply Well: 0 ft. Z ft ?i 1 Ju l/.Il.
DMonitoring ❑Recovery ft it t! r
Injection Well: _
-
❑Aquifer Recharge • ❑Groundwater Remediation- 19.SAND/GRAVEL PACK(if applicable)A 4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENFMEFHOD
❑Aquifer Test ❑Stormwater Drainage it. rt.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(0 ft. S ft Rd C,la.c' S9t//
4.DateWell(s),Completed:O91a4Ir&L} WellU)# A4.4-3Si s ft 9-S f 3;7own k irAer v/W Rock.
5a.Well Location: it' 3it 6- Lc 1
,1 rw f'I G ro ek .
`" ^ _�7t • ft ft.
�,ivtcQ`*-� aTiNixlQ l 1 I5pn .t" `. ''.'...
Facility/OwnerNaMe - . Facility)D#(if applicable) ft. ft. -- i . "
(P:Ls3 /jjoocdsdcJ.. RC( I- ?Wo r\o,Ale- 2-1 S`73 ft. O C T 2 i 2024
Physical Address,City;and Zip • it_ • it.'
U.p,r5ate, A-4T -3S 21.REMARKS Ds;,;t:„..� ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. • ratio .
3(0. 3 i 7 N mil' F1 9 9 g Wii
o 03
6.Is(are)the well(s): 1�Permanent or ❑Temporary Si uro Ce d Contractor Dat
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 111No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out;mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 3 t�1 (it) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -�C7 (ft) Information ProcessingUnit,1611 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" - P +
11.Borehole diameter: (0 "" (in.)- 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ! �OTK)r2 y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) _ - ' " county environmental health department of the county where installed "
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA'
13a.Yield(gpm) Off rJ, Method of test: q Permit Program,1611 MSC,Raleigh,NC 27699-1611
O
0 4
p � (� i,
13b.Disinfection type: 1(U(`[,I P� Amount: I l,l- OZ.--
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018